Content Innovation, Claims Editing – Specialty Pharmacy

Job not on LinkedIn

🔥 6 minutes ago

🇺🇸 United States – Remote

💵 $135k - $165k / year

⏰ Full Time

🟠 Senior

🔴 Lead

✍️ Content Marketing Manager

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 $10M Series A - Machinify on 2018-10

Healthcare • Consulting • Logistics

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Monitor and interpret CPT, HCPCS, ICD-10-CM, NCCI, MUE, CMS, specialty society, FDA, drug compendia, NCCN, pricing, and payer policy sources • Translate coding rules, clinical guidelines, and reimbursement policy into precise, testable editing logic • Document edit sources, rationale, and scope for traceability and appeals • Maintain content through code updates, policy changes, and performance reviews • Build and maintain specialty drug edits for billing units, NDC-to-HCPCS crosswalks, dosing, maximum units, dose rounding, and JW/JZ modifiers • Cover oncology, immunology, rare disease, biosimilars, and other high-cost therapeutic areas • Use claims data to test concepts, size opportunities, and measure hit rates, false positives, and savings • Review production results to identify gaps, overreach, and missed opportunities • Partner with Product, Engineering, and Data Science on requirements, logic specifications, test cases, and clinical context • Evaluate AI tools and apply expert judgment to AI-generated content • Support client policy review, edit approval, appeals, and content roadmap improvements • Own a content domain and move data-validated concepts into production

🎯 Requirements

• 7+ years of experience in claims editing, clinical coding, Payment Integrity, or payer policy, with hands-on experience authoring or validating edits • Active coding credential, such as CPC, CCS, CCS-P, CPMA, or CIC, or a clinical license such as RN paired with deep coding experience • Deep, current knowledge of CPT, HCPCS, ICD-10-CM, modifiers, NCCI, MUEs, coding guidelines, and documentation requirements • Working knowledge of reimbursement methodologies, including fee schedules, DRGs, APCs, and professional and facility billing • Experience sourcing and interpreting CMS manuals, NCDs and LCDs, AMA guidance, and payer policies • Strong analytical skills and comfort working with claims data using SQL, Excel, or similar tools • Experience working with Product, Engineering, Data Science, or other multidisciplinary teams • Clear written communication and ability to explain complex coding and clinical logic to nonclinical audiences • Curiosity about AI tools and willingness to use them in daily content work • At least 3 years of hands-on experience with medical benefit drug billing, coding, or policy, including HCPCS J-codes, NDCs, billing units, drug-related modifiers, and ASP-based reimbursement • Sound judgment and comfort working in a fast-moving build-and-scale environment

🏖️ Benefits

• PTO, Paid Holidays, and Volunteer Days • Eligibility for health, vision and dental coverage • 401(k) plan participation with company match • Flexible spending accounts • Tuition Reimbursement • Company-paid life insurance • Company-paid short-term disability • Company-paid parental leave • Remote and hybrid work options